Page 1 of 2 STATE OF FLORIDA School Entry Health Exam

Page 1 of 2

STATE OF FLORIDA School Entry Health Exam

To Parent/Guardian: Please complete and sign Part I -- Child's Medical History. State law for school entry requires a health examination by a legally qualified professional. Additional requirements may be determined by local school districts.

(Please Print)

Name of Child (Last, First, Middle)

Birth Date

Sex

Address (Street)

School

Grade

City and ZIP Code

Home Telephone Number

Parent/Guardian (Last, First, Middle)

PART I -- CHILD'S MEDICAL HISTORY To Parent/Guardian: Please check answers to questions 1 through 8 below in the column on the left. (Please explain any "Yes" answers in the space provided below.)

1. Yes No Any concerns about general health (eating and sleeping habits, weight, etc.)? 2. Yes No Any other specific illness or social/emotional or behavioral problems? 3. Yes No Any allergies (food, insects, medication, etc.)? 4. Yes No Any prescription medication (daily or occasionally)? 5. Yes No Any problems with vision, hearing, or speech (glasses, contacts, ear tubes, hearing aids)? 6. Yes No Any hospitalization, operation, or major illness (specify problem)? 7. Yes No Any significant injury or accident (specify problem)? 8. Yes No Would you like to discuss anything about your child's health with a school nurse?

To Parent/Guardian: Please explain any "Yes" answers from above.

I am the parent/guardian of the child named above. I give permission for the information on PARTS I and II of this form

provided about my child to be reviewed and utilized only by the staff of this school and any school health personnel providing

school health services in the district for the limited purpose of meeting my child's health and educational needs.

Signature of Parent/Guardian

Date

Partnership for School Readiness Recommendations for Prekindergarten and Kindergarten

To Parent/Guardian: Please obtain the services listed below in order to find any problems. Please work with your health care provider to

correct or treat any problems that may reduce your child's ability to learn in school. (These services are recommended but not required.)

1. Comprehensive Vision Examination (3-5 years of age)

Please describe any corrective action for any problems detected and

Date of Exam:

any accommodations required.

Results of Exam:

Health Care Provider: (check one) Optometrist

Ophthalmologist

2. Comprehensive Dental Examination Date of Exam: Results of Exam:

Please describe any corrective action for any problems detected and any accommodations required.

Dentist:

3. Hearing Screening Date of Exam: Results of Exam:

Please describe any corrective action for any problems detected and any accommodations required.

Health Care Provider:

DH3040-CHP-07/2013

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download